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Background The optimal strategy for surgical management of papillary thyroid carcinoma invasion of the recurrent laryngeal nerve remains controversial. Our aim was to evaluate the efficacy of 2 surgical methods and provide detailed descriptions of microscope-guided partial layer resection and intralaryngeal reconstruction of the recurrent laryngeal nerve. Methods This retrospective study enrolled 85 patients with papillary thyroid carcinoma who underwent initial surgical excision for invasion of the recurrent laryngeal nerve. Twenty-seven patients (28 recurrent laryngeal nerve sites) underwent partial layer resection, and 11 patients (11 recurrent laryngeal nerve sites) underwent intralaryngeal reconstruction of the recurrent laryngeal nerve. The remaining patients underwent either only resection or resection with immediate reconstruction of the recurrent laryngeal nerve. Pre and postoperative phonetic function and rates of locoregional recurrence were extracted from medical charts for analysis. Results Isolated locoregional recurrence specific to the aerodigestive tract was identified in 1 patient (3.7%) in the partial layer resection group and 1 patient (9.1%) in the intralaryngeal reconstruction group. Seventy-five percent of patients in the partial layer resection group recovered or had preserved vocal cord function, and the mean maximum phonation time of the patients with postoperative complete vocal cord palsy was 15.3 seconds. The mean maximum phonation time of the patients, excluding 4 patients with permanent stoma in the intralaryngeal reconstruction group, was 22.3 seconds. The mean maximum phonation time of either group was longer than that of patients with recurrent laryngeal nerve resection only and comparable with that of patients with recurrent laryngeal nerve resection and immediate reconstruction. Conclusion Patients who underwent either partial layer resection or intralaryngeal reconstruction had low rates of locoregional recurrence specific to the aerodigestive tract and good postoperative functional outcomes.

Papillary thyroid carcinoma (PTC) is a relatively indolent disease, despite the high incidence of lymph node metastases. Although less frequent, some upper mediastinal metastases of PTC cannot be removed without sternal resection. In this study, we investigated the prognostic impact of upper mediastinal dissection (UMD) by sternotomy on patients with mediastinal metastases of PTC. Charts of patients with PTC who underwent surgical treatment at our institution between 2006 and 2018 were retrospectively reviewed. Fifty-eight patients with upper mediastinal metastases were enrolled. Kaplan-Meier survival curves were compared, and Cox hazard regression models were used for analyses. Of the 58 patients with mediastinal metastasis, 12 (20.7%) underwent dissection of the prevascular nodes, 51 (87.9%) underwent dissection of the upper paratracheal nodes, and 14 (24.1%) underwent dissection of the lower paratracheal node. The preferred site of mediastinal metastasis was the upper paratracheal nodes. The 5 and 10-year disease-specific survival rates for patients after UMD were 74.6% and 58.7%, respectively. Among 25 patients (43.1%) with locoregional recurrence, 12 (20.7%) had mediastinal recurrence and 7 were eligible for additional UMD. Although distant metastasis was the predominant poor prognostic factor, mediastinal recurrences were more frequently unresectable than cervical recurrences, suggesting that mediastinal recurrence is a poor prognostic factor. Mediastinal metastases larger than 30 mm or metastases to the lower paratracheal nodes are considered a risk factor for mediastinal recurrence. UMD by sternotomy for patient with upper mediastinal metastases which are difficult to resect via transcervical approach is an effective treatment option to improve patient prognosis.

Primary hyperparathyroidism is usually caused by parathyroid adenoma; however, parathyroid carcinoma is a rare cause. We report a rare case of 74-year-old female of primary hyperparathyroidism caused by parathyroid carcinoma (PC) and coexisting multiple parathyroid adenomas. She was referred to our hospital for primary hyperparathyroidism and a suspected thyroid tumor. She had no family history of malignant tumor. Computed tomography (CT) and ultrasonography of the neck revealed some masses posterior to both thyroid lobes. Those masses were believed to be parathyroid lesions. However, another mass located posterior to the right upper thyroid lobe seemed to be heterogeneous, which indicated a malignant thyroid tumor as well as parathyroid tumor. The preoperative diagnosis was multiple parathyroid adenoma and suspicious incidental thyroid carcinoma. Therefore, the patient underwent total parathyroidectomy and thyroidectomy. The histopathological diagnosis was parathyroid carcinoma coexisting with multiple parathyroid adenomas. There was no evidence of recurrence at 1 year after the surgery. It was difficult to diagnose PC preoperatively. Few rare cases of PC coexisting with parathyroid adenoma in multiple endocrine neoplasia type 1 (MEN1) have been reported. Therefore, careful follow-up was necessary considering the possibility of MEN1, though she did not wish for a genetic examination.

BackgroundTransoral robotic surgery is frequently described, driven by the desire to offer a less morbid alternative to chemoradiation. However, the objective evaluation of post-operative function has rarely been reported. Therefore, high-resolution manometry was used in this study to evaluate the impact of changes in peri-operative swallowing function on pharyngeal pressure events.MethodsTen patients with various stages of oropharyngeal cancer underwent transoral surgery. High-resolution manometry and videofluoroscopic swallow studies were performed before surgery and two months afterwards. The following parameters were obtained: velopharyngeal and mesopharyngeal post-deglutitive upper oesophageal sphincter pressures, velo-meso-hypopharyngeal contractile integral, upper oesophageal sphincter relaxation pressure, and pharyngeal velocity.ResultsThere was no significant difference in pharyngeal pressure or contractile integral pre- versus post-operatively. However, pharyngeal velocity was significantly higher post-operatively than pre-operatively.ConclusionHigh-resolution manometry showed that transoral surgery in patients without pre-operative dysphagia preserved pharyngeal constriction. However, transoral surgery might produce scar formation in the pharynx, which could lead to narrowing of the pharynx.

BackgroundIn endoscopic cricopharyngeal myotomy, surgeons sometimes have concerns about performing an adequate incision with only a narrow intra-cavital view from one direction. In order to overcome these issues, fluoroscopic radiography was used during endoscopic cricopharyngeal myotomy.MethodsPeri-operative fluoroscopic radiography was utilised to check the position of the diverticuloscope, and to confirm the extent of the incision during surgery. A balloon catheter was used to determine whether the cricopharyngeal muscle was sufficiently resected. Blood loss, peri-operative complications, and functional oral swallowing scale and penetration aspiration scale scores were evaluated.ResultsIn 12 out of 15 patients, intra-operative fluoroscopic radiography showed the diverticuloscope positioned in the post-cricoid area, and the cricopharyngeal muscle was raised and the surgery completed without adverse effect. Swallowing functions improved following surgery.ConclusionIntra-operative fluoroscopy might improve endoscopic cricopharyngeal myotomy by allowing surgeons to confirm the extent of resection, and by reducing peri-operative morbidity and complication rates.

Piriform sinus fistula (PSF) is a rare branchial anomaly that causes repetitive acute suppurative thyroiditis or deep neck abscess. The definitive treatment of PSF is open neck surgery. However, such surgery has a cosmetic problem and a high risk of recurrence. Furthermore, identifying the fistula is difficult due to previous repetitive infections. We report a case of esophageal submucosal abscess caused by PSF treated with endoscopic mucosal incision. The patient underwent transoral video laryngoscopic surgery (TOVS), and endoscopy as well as fluoroscopy revealed complete closure of PSF without any complication. TOVS is a novel surgical technique for the definitive treatment of PSF with esophageal submucosal abscess.

Cineradiography enables the second stage of swallowing to be analyzed visually in hyoid and laryngeal movements during swallowing, but cost and preparation time have limited its clinical dissemination. To overcome this, we computerized quantitative video fluorographic imaging using commercially available DIPP-Motion Pro 2D® software. This has the advantages of 1) DV images are fed to the computer as animation and analyzed directly; 2) numerous points can be marked and tracked automatically, 3) with coordinate setting and scale correction, movement distance and velocity are measured automatically, and 4) functions synchronizing graphs with cineradiography video facilitate visual understanding. We quantitatively studied swallowing in 6 subjects without dysphagia. Median hyoid bone movement is 10.5 mm on the abscissa and 16.2 mm on the ordinate. Median laryngeal movement is 9.3 mm on the abscissa and 25.1 mm on the ordinate. Maximum bolus is 1011.3 mm/sec. We analyzed swallowing conveniently and effectively, displaying data with visual information. This makes it a handy tool for analyzing swallowing quantitatively in clinical practice. It also enables us to exchange information effectively with other medical personnel and gain informed consent.

A 49-year-old man noticed a resting tremor in his right hand and was diagnosed with Parkinson's disease (PD) at the age of 43. Soon thereafter, he noticed a right neck mass that only appeared when he swallowed and was accompanied by an uncomfortable sensation. At the age of 49, he was admitted to our hospital to adjust his medication for PD and to examine the neck mass. The subcutaneous mass was round, soft, and approximately 3 cm in diameter. The symptoms in his neck showed no progression. Resting tremors and rigidity due to his PD were predominantly observed on his right side, but his postural reflex was intact. Cervical echogram revealed that the mass was the belly of the OM itself. Thus, the patient was diagnosed with omohyoid muscle syndrome (OMS). It can be surmised that some susceptibility of the OM itself and/or structural fragility in the surrounding tissues would be involved in the pathogenesis of OMS. In this case, considering that OMS occurred soon after symptoms of PD appeared, we speculated that muscle tone abnormalities due to PD played a role in the development of OMS.

A 6-month-old boy with persistent primitive trigeminal artery (PPTA) presented with stridor, dysphagia, delayed motor development and postural neck and shoulder dystonia. Magnetic resonance imaging/angiography and ultrasonography revealed PPTA, with flow from the dilated basilar artery to the right internal carotid artery, lower brainstem compression by the dilated basilar artery, and cerebellar vermis hypoplasia. Evoked potentials showed lower pons and medulla oblongata functional disruption. These lesions may be related to vascular etiology in the lower brainstem or to congenital malformation syndrome involving infratentorial structures. The relationship of this condition to Möbius syndrome is discussed.

A case of transitional cell carcinoma (TCC) of the frontal sinus is reported. An 83-year-old man complained of left exophthalmos and nasal obstruction. On examination, the nasal cavity was blocked with a polypoid swelling. Computed tomography and magnetic resonance imaging demonstrated tumor in the frontal sinus and mucocele in the paranasal sinus. The mass in the left frontal sinus was excised and diagnosed as TCC. The treatment was performed by a linear accelerator. The prescribed dose was 70Gy. Irradiation was performed without effect, and the patient died 1 year later. Previous reports of TCC in the paranasal sinus are reviewed and discussed.

Innominate artery fistulas require a surgical procedure, although the prognosis is usually very poor because of complications such as re-bleeding and infection. A 50-year-old man presented with laryngeal carcinosarcoma (T1a, N0, M0). Partial laryngectomy was performed but there was a recurrence; therefore, total laryngectomy, total thyroidectomy, right radical neck dissection, left functional neck dissection, skin-combined resection and D-P flap were performed. On postoperative day 6, after intense coughing, copious hemorrhage from the tracheostoma was demonstrated. Immediately, bleeding was arrested by pressing the tracheostoma. Fistula of the innominate artery was then repaired using left great saphenous vein, but recurrent perforation of the innominate artery developed. Therefore, innominate artery transection and omentopexy were performed. These results demonstrate that in cases of trachea-innominate artery fistula, innominate artery transection should be performed first.

We reported a rare case of perforation of the piriform sinus caused by gastroenterological endoscopy examination, leding to deep cervical abscess. The patient was a 56-year-old man who complained of dyspnea, high-grade fever and neck pain after gastroenterological endoscopy examination. Computed tomography revealed a deep cervical abscess and obstruction of the airway. We immediately, performed drain-age under general anesthesia, and found a perforation at the piriform sinus. He was treated with frequent wound washing and the daily intravenously instillation of antibiotics for anaerobic bacteria, and was discharged 31 days after the operation. Early diagnosis and operation are important for the management of deep cervical abscess.

In this case report, we present genetic differences in two morphine-related gene sequences, UDP-glucuronosyltransferase 2B7 (UGT2B7) and mu opioid receptors (MOR1), in two cancer patients whose clinical responses to morphine were very different [i.e., sensitive (patient 1) and low responder (patient 2)]. In addition, allelic variants in the UGT2B7 gene were analyzed in 46 Japanese individuals. Amplified DNA fragments for the two genes of interest were screened using single strand conformation polymorphism and then sequenced. In the UGT2B7 gene, 12 single nucleotide polymorphisms (SNPs) were newly identified with an allelic frequency ranging from 0.022 to 0.978. Six SNPs in the promoter region (A-1302G, T-1295C, T-1111C, G-899A, A-327G, and T-125C) and two coding SNPs (UGT2B7*2 in exon 2 and C1059G in exon 4) appeared to be consistently linked. Remarkable differences in the nucleotide sequence of UGT2B7 were observed between the two patients; in contrast to patient 1 who had "reference" alleles at almost SNP positions, but a rare ATTGAT*2(AT)C haplotype as homozygosity, patient 2 was a homozygous carrier for the predominant GCCAGC*1(TC)G sequence. Serum morphine and two glucuronide concentrations in patient 2 suggest that the predominant GCCAGC*1G sequence was not associated with a "poor metabolizer" phenotype. In the MOR1 gene, patient 1 had no SNPs, whereas patient 2 was a heterozygous carrier for both the G-1784A and A118G alleles. The present study describes substantial differences in genotype patterns of two genes of interest between the two patients. The results necessitate larger trials to confirm these observations in larger case control studies.

From January 1990 to December 1999, we treated twelve patients with cervical lymph node tuberculosis. The diagnosis was confirmed by histopathological findings of biopsy, 10 cases by resection of lymph node, 1 case by fine needle aspiration biopsy and 1 case was diagnosed following resection of lymph node at another hospital. After diagnosis, all patients received antituberculous chemotherapy and one patient with pocket formation underwent total resection of neck masses with infectious skin. Four cases were lost to follow-up, but the others showed good response and had no recurrence.Tuberculosis is an important infectious disease demanding constant attention because of the possibility of herd infection. We should consider tuberculosis when cervical lymph node swelling is seen, and early diagnosis and treatment are needed to prevent the spread of infection to others. Antituberculous chemotherapy is effective, however, when pocket and abscess formation occur, combination therapy of chemotherapy and operation such as neck dissection are needed in early course.

Hearing loss is a rare complication of mumps infection, however improvement of mumps-related deafness is difficult. In Japan, immunization against mumps is not required and mumps-related deafness is thought to have increased.We encountered three cases of unilateral sensorineural hearing loss due to mumps infection. The diagnosis was based on criteria determined by the Acute Profound Deafness Committee in Japan. All cases were treated for sudden deafness with routine steroid therapy.Case 1 was a 5-year-old boy. He was diagnosed as having mumps-associated hearing loss and his hearing improved. Case 2 was a 27-year-old woman, diagnosed as having mumps-related deafness and her hearing was not improved by therapy. Case 3 was a 43-year-old man, diagnosed as having mumps-associated deafness, but his hearing was not improved with therapy.Sensorineural hearing loss due to mumps infection is considered difficult to recover. However, some cases showing improvement have been reported such as our case 1. Early diagnosis and therapy are thought to be needed. Immunization against mumps should be required from the perspective of preserving hearing.

We previously reported that dietary glucosylceramides show cancer-prevention activity in a mouse xenograft model of human head and neck cancer cells (SCCKN). However, the mechanism was unclear. Ceramides, metabolites of glucosylceramides, induce apoptotic cell death in various malignancies. Here, we investigated the inhibitory effects of dietary glucosylceramides on tumor growth in vivo and in vitro. SCCKN were subcutaneously inoculated into the right flanks of NOD/SCID mice. Mice were treated with or without dietary glucosylceramides (300 mg/kg) daily for 14 consecutive days after confirmation of tumor progression. Microvessel areas around the tumor were assessed by hematoxylin–eosin staining and immunohistochemistry of CD31, and, as markers for angiogenesis, protein levels of VEGF, VEGF receptor-2, and HIF-1α were assessed by Western blotting. Mass spectrometry was performed to measure the levels of sphingolipids in mouse serum after treatment with dietary glucosylceramides. Oral administration of glucosylceramides significantly decreased SCCKN growth in the xenograft model with inhibition of angioinvasion. In tumor-invasive areas, VEGF and HIF-1α in the tumor cells, and VEGF receptor-2 in endothelial cells decreased after treatment with dietary glucosylceramides. Dietary glucosylceramides increased serum levels of sphingosine-based ceramides as compared to the control. In SCCKN and UV♀2 cells, C6-ceramide suppressed the expressions of VEGF, VEGF receptor-2, and HIF-1α in vitro. These results suggest that dietary glucosylceramides trigger the de novo pathway of ceramide synthesis, indicating that sphingosine-based ceramide suppresses the growth of head and neck tumors through the inhibition of pro-angiogenic signals such as VEGF, VEGF receptor-2, and HIF-1α.

Objectives: Laryngotracheal separation (LTS) is an ideal surgical method for intractable aspiration; however, the oral side of the tracheal stump can easily disintegrate. Therefore, we developed a modified LTS method. We performed subglottic laryngeal closure (SGLC) as a new surgical method and evaluated the outcomes. Methods: We retrospectively analyzed the medical records of 36 patients (28 male and 8 female; 15 to 91 years of age) who underwent SGLC between 2007 and 2011 at Tottori University Hospital, Japan. Operative data (operative time, intraoperative bleeding, and time to drain removal), outcomes (aspiration and changes in nutritional status), and complications with regard to the surgical method were examined. The occurrence of a subcutaneous proximal laryngeal stump fistula was evaluated by videofluoroscopy. Results: The SGLC was performed safely in all patients. Fistulization was observed in only 1 of the patients (2.8%), and major bleeding after surgery was observed in 1 patient (2.8%). The procedure relieved aspiration pneumonia in all patients. Conclusions: We conclude that SGLC is effective for treating and preventing pulmonary aspiration. The incidence of postoperative complications, particularly that of subcutaneous fistulas, was very low. Therefore, this method may be useful for patients in poor condition.

Background: Magnetic resonance (MR) imaging of parotid gland tumors has been widely reported, although few reports have evaluated the capsule of parotid gland tumors in detail. Purpose: To evaluate the diagnostic usefulness of 3.0 T MR imaging with surface coils for detection of the parotid gland tumor capsule, and to clarify the characteristics of the capsules. Material and Methods: Seventy-eight patients with parotid gland tumors (63 benign and 15 malignant) were evaluated. Axial and coronal T2-weighted and contrast-enhanced T1-weighted images were obtained using a 3.0 T MR scanner with 70 mm surface coils. It was retrospectively assessed whether each parotid gland tumor was completely surrounded by a capsule. The capsule was classified as regular or irregular in terms of capsular thickness, and as none, mildly, or strongly enhancing in terms of contrast enhancement. Visual interpretations were compared with histopathological findings to evaluate the diagnostic ability of MR imaging to detect parotid gland tumor capsules. Statistical evaluation was conducted concerning the presence of capsules, capsular irregularity, and the difference in contrast enhancement between benign and malignant tumors, and that between pleomorphic adenomas and Warthin's tumors. Results: Capsules completely surrounding the tumor on MR imaging yielded a sensitivity of 87.7% (50/57), specificity of 90.5% (19/21), and accuracy of 88.5% (69/78). Benign tumors had a capsule completely surrounding the tumor significantly more often than malignant tumors ( P = 0.009). Concerning capsular irregularity, malignant tumors tended to have more irregular capsules than benign tumors, although there were no significant differences. The capsules of malignant tumors enhanced significantly more strongly than those of benign tumors ( P = 0.018). Conclusion: 3.0 T MR imaging using surface coils could correctly depict parotid gland tumor capsules in most cases. Most benign and some malignant tumors had capsules completely surrounding the tumors. Malignancy should be considered in tumors with irregular and strongly enhancing capsules.

It is important to know whether a parotid gland lesion is in the superficial or deep lobe for preoperative planning. We aimed to investigate the ability of 3.0 T magnetic resonance (MR) imaging with surface coils to identify the intraparotid facial nerve and locate parotid gland lesions, in comparison to other indirect landmark methods.We retrospectively evaluated 50 consecutive patients with primary parotid gland lesions. The position of the facial nerve was determined by tracing the nerve in the stylomastoid foramen and then following it on sequential MR sections through the parotid gland. The retromandibular vein and the facial nerve line (FN line) were also identified. For each radiologist and each method, we determined the diagnostic ability for deep lobe lesions and superficial lobe lesions, as well as accuracy. These abilities were compared among the three methods using the Chi-square test with Yates' correction.Mean diagnostic ability for deep lobe lesions, the diagnostic ability for superficial lobe lesions, and accuracy were 92%, 86%, 87%, respectively, for the direct identification method; 67%, 89%, 86%, respectively, for the retromandibular vein method; and 25%, 99%, 90% , respectively, for the FN line method. The direct identification method had significantly higher diagnostic ability for deep lesions than the FN line method (P 0.01), but significantly lower diagnostic ability for superficial lobe lesions than the FN line method (P 0.01).Direct identification of the intraparotid facial nerve enables parotid gland lesions to be correctly located, particularly those in the deep lobes.

To explore severe toxicities induced by irinotecan-based chemotherapy and UGT1A1*6/*28 and SLCO1B1*15/*15 genotypes.A 66-year-old Japanese male diagnosed with left pharyngeal carcinoma (T2N2bM0, stage IVA) was treated with irinotecan (70 mg/m(2)) on days 1, 8 and 15 in combination with docetaxel (60 mg/m(2)) on day 1 of a 28-day cycle. After the first cycle, he suffered marked toxicities, including grade 4 diarrhea and febrile grade 4 neutropenia. Plasma concentrations of irinotecan, SN-38 and SN-38G were measured, and extensive accumulation of SN-38 was observed. Genotyping of UGT1A1 and OATP1B1 proteins showed UGT1A1*6/*28 and SLCO1B1*15/*15, respectively, which are known to lead to extremely low glucuronidation and transport activities of substrate drugs.The severe toxicities in this patient are attributable to the extensive accumulation of SN-38, which may result from a synergistic or additive effect of low metabolic (UGT1A1*6/*28) and transport (SLCO1B1*15/*15) capabilities.

DIPP-Motion Pro 2D® software is a new computerized system for quantitative analysis of motion of an object on screen automatically. It has been reported that cineradiography has been performed to analyze hyoid and laryngeal movements during swallowing; however, due to cost and preparation time, this method has not yet reached the clinical application stage. To overcome these problems, we have devised a new computerized system for quantitative analysis of video fluorography images using commercial “DIPP-Motion Pro 2D” software. DIPP-Motion Pro 2D® enables the efficient analysis including motion image sequence analysis, automatic tracking, measurement of distance and velocity, and graph display. With this system, quantitative studies were performed to analyze swallowing movements in 6 subjects without dysphagia. The median hyoid bone movement is 1.03cm(X-axis),1.59cm(Y-axis). The median laryngeal movement is 0.91cm(X-axis),2.46cm(Yaxis).The maximum bolus speed is 99.15cm/sec. We can analyze swallowing function conveniently and effectively with this system. It also could display the data with visual information. Therefore, it may become a tool to analyze swallowing function quantitatively in clinical practice. It also allows us to effectively exchange information with other medical personnel and gain informed consent. We can analyze swallowing function conveniently and effectively with this system, and it displays the data with visual information. Therefore, it may become a tool to analyze swallowing function quantitatively in clinical practice. Furthermore, it helps us to effectively exchange information with other medical personnel and gain informed consent. Cineradiography has made it possible to perform detailed visual analysis of the second stage of swallowing (hyoid and laryngeal movements) . Due to cost and preparation time, this method has not yet reached the clinical application stage. To overcome these problems, we have devised a new computerized system for quantitative analysis of video fluorography images using commercial “DIPP-Motion Pro 2D® software.

Background The reflex cough test is useful for detecting silent aspiration, a risk factor for aspiration pneumonia. However, assessing the risk of aspiration pneumonia requires measuring not only the cough reflex but also cough strength. Currently, no reflex cough testing device is available that can directly measure reflex cough strength. We therefore developed a new testing device that can easily and simultaneously measure cough strength and the time until the cough reflex, and verified whether screening with this new instrument is feasible for evaluating the risk of aspiration pneumonia. Methods This device consists of a special pipe with a double lumen, a nebulizer, and an electronic spirometer. We used a solution of prescription-grade L-tartaric acid to initiate the cough reflex. The solution was inhaled through a mouthpiece as a microaerosol produced by an ultrasonic nebulizer. The peak cough flow (PCF) of the induced cough was measured with the spirometer. The 70 patients who participated in this study comprised 49 patients without a history of pneumonia (group A), 21 patients with a history of pneumonia (group B), and 10 healthy volunteers (control group). Results With the novel device, PCF and time until cough reflex could be measured without adverse effects. The PCF values were 118.3 ± 64.0 L/min, 47.7 ± 38.5 L/min, and 254.9 ± 83.8 L/min in group A, group B, and the control group, respectively. The PCF of group B was significantly lower than that of group A and the control group (p